Retrospective Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Apr 26, 2020; 8(8): 1414-1423
Published online Apr 26, 2020. doi: 10.12998/wjcc.v8.i8.1414
Bedside score predicting retained common bile duct stone in acute biliary pancreatitis
Tawfik Khoury, Anas Kadah, Mahmud Mahamid, Amir Mari, Wisam Sbeit
Tawfik Khoury, Anas Kadah, Mahmud Mahamid, Amir Mari, Wisam Sbeit, Faculty of Medicine in the Galilee, Bar-Ilan University, Safed 1311502, Israel
Tawfik Khoury, Anas Kadah, Wisam Sbeit, Department of Gastroenterology, Galilee Medical Center, Nahariya 22100, Israel
Tawfik Khoury, Mahmud Mahamid, Amir Mari, Gastroenterology and endoscopy units, The Nazareth Hospital EMMS, Nazareth 16100, Israel
Author contributions: Khoury T and Sbeit W contributed to conception and design of the study; Khoury T, Kadah A, Mahamid M, Mari A and Sbeit W contributed to data collection and analysis; Khoury T and Sbeit W contributed to critical revision of the manuscript; Khoury T, Kadah A, Mahamid M, Mari A and Sbeit W approved the final version to be published.
Institutional review board statement: The study was approved by the local ethical committee, number 0189-17-NHR.
Informed consent statement: Written informed consent was waived by the IRB due to the retrospective, non-interventional nature of the study.
Conflict-of-interest statement: The authors declare no conflict of interest regarding this manuscript.
Data sharing statement: Statistical code and dataset available from the corresponding author at (tawfikk@gmc.gov.il). Consent was not obtained for data sharing but the presented data are anonymized and risk of identification is low.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Tawfik Khoury, MD, Doctor, Lecturer, Senior Researcher, Department of Gastroenterology, Galilee Medical Center, POB 12000, Naharia 2210001, Israel. tawfikkhoury1@hotmail.com
Received: December 15, 2019
Peer-review started: December 15, 2019
First decision: January 7, 2020
Revised: March 3, 2020
Accepted: April 15, 2020
Article in press: April 15, 2020
Published online: April 26, 2020
Processing time: 128 Days and 18.2 Hours
ARTICLE HIGHLIGHTS
Research background

Gallbladder stones are the commonest cause of acute biliary pancreatitis. Despite that most of the stones are expelled spontaneously through the papilla due to their small size; about 20% to 30% of patients with acute biliary pancreatitis will have persistent common bile duct (CBD) stones. Thus, it is important to identify this subset pf patients since they will need endoscopic stone removal. In real clinical practice, the decision to perform an imaging modality for clarifying a suspicion of CBD stone or to proceed directly to endoscopic retrograde cholangiopancreatography (ERCP) because of strong suspicion of CBD stone is mostly based on combinations of clinical, laboratory and ultrasound findings. Many investigators have noted that the probability of CBD stones is higher in the presence of multiple predictors. We characterized clinical, laboratory and radiological parameters which are easily available that can predict the presence of retained CBD stones among patients hospitalized with acute biliary pancreatitis.

Research motivation

The main driver for performing this study was to develop simple bedside score based on easily available parameters that predicts the presence of retained biliary stones, since identification of CBD stone is crucial to relieve biliary obstruction. This score might stratify patients into low or high-risk probability for retained CBD stone and subsequently assist clinicians in performing further confirmatory/therapeutic tests.

Research objectives

Given that retained biliary in the setting of acute biliary pancreatitis required performing certain imaging such as endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP) which are either invasive or not widely available, we aimed to explore simple easily available clinical, laboratory and imaging parameters that predict CBD stone with good statistical performance.

Research methods

We performed a single center retrospective case control study including 154 patients with presumed diagnosis of acute biliary pancreatitis who underwent EUS. The strength of our study is that we relied on EUS as a gold standard for the diagnosis of CBD stones, and second that we aimed to combine several parameters to generate scoring system that could predict CBD stone with high probability.

Research results

After assessment of several clinical, laboratory and radiological parameters, we were able to identify 3 parameters that were statistically significant on univariate and multivariate regression analysis including age, GGT level and CBD width by US. Using these variables, we generated a score predicting the presence of retained CBD stones. A score that ranges from 51.28 to 73.7 has a very high specificity (90%-100%) for CBD stones, while a low score that ranges from 9.16 to 41.04 has a high sensitivity (82%-100%), as the patients with the higher score might be referred immediately for ERCP without the need for further investigations, while the low score cut-off points might benefit from watch and see strategy or other confirmatory tests for CBD stones.

Research conclusions

For the first time, we were able to generate a simple scoring system that predicts the presence of retained CBD stones among patients with acute biliary pancreatitis. Currently, the professional societies including the American Society of Gastrointestinal Endoscopy and the ESGE are relying on individualized predictors of CBD stones. The ability to incorporate several variables into one scoring system further improve the diagnostic accuracy of this score, as is known that combining several predictors for CBD stone is superior to each predictor alone. Thus, our score might be already introduced into the daily clinical practice that guide therapeutic decisions.

Research perspectives

The diagnosis of retained CBD stone in acute biliary pancreatitis is somehow challenging as it based on single abnormal laboratory or ultrasonographic tests. However, once a suspicion is raised, most clinicians proceed to other confirmatory tests, mainly EUS which is invasive test or MRCP which is costly and not easily available. However, as we shown that combining predictors for CBD stone into one scoring system had an excellent diagnostic performance. This will allow clinicians to avoid performing other unnecessary imaging studies. Large prospective cohort studies assessing combination of several CBD stone simple predictors are warranted.